Addressing Substance Use Disorders Among Families Involved with the Child Welfare System: A Cross-Agency Collaboration

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Expiration Date: October 12, 2020

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_{Caregiver Demographic} Form

Site ID: _ _ _ _ _

Please provide some information about yourself by completing this questionnaire. We will not report any of your responses by name. Thank you.

BACKGROUND
In what county do you currently live?	____________________________________________
What is your sex	Male Female Other
How would you describe your racial background? Select all that apply.	American Indian or Alaska Native Asian Black or African American		Native Hawaiian or Other Pacific Islander White
Would you describe yourself as Hispanic or Latino?	Yes No
What is your current marital status?	Single Married Living with someone		Separated Divorced Widowed
What is the highest education level completed? Select one.	11th grade or less 12th grade but no high school diploma High school diploma or GED Some college or technical school		Associate degree Bachelor’s degree Master’s degree Doctorate degree Professional degree (MD, JD, etc.)
What is your current employment status	Full-time employment for wages Part-time employment for wages Self-employed for wages Presently not employed outside the home, looking for work		Presently not employed outside the home, not looking for work Disabled/unable to work Refused/unknown
What is your total household income?	Less than $25,000 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999		$75,000 to $99,999 $100,000 to $149,999 $150,000 or more I prefer not to say
Do you currently receive any public government benefits (e.g., Medicaid, food stamps, SSI, or welfare cash assistance)?	Yes No
For Focus Groups: CAREGIVING
We are interested in learning more about your role as a caregiver and your relationship to the children for whom you provide care. Please answer the following questions about the minor children (under 18 years) you currently care for who live in your home.
What type of caregiver would you say you are? Select all that apply.	Adoptive parent or foster-to-adopt parent Biological parent Step parent Relative caregiver or guardian		Short-term foster Long-term foster Therapeutic foster Other (please describe) __________________________
How many minor children (under 18 years of age) are you currently caring for that live in your home full time?	None 1 2	3 4		5 6 or more
What are the ages of these children?	______________________________________________________________
How many of these children are your biological, adopted, or step children?	None 1 2	3 4		5 6 or more
For how many of these children are you a kinship caregiver (relative by blood or marriage)?	None 1 2	3 4		5 6 or more
How many of the minor children in your care are foster children?	None 1 2	3 4		5 6 or more
Are you involved with child welfare for any of the children involved in your care?	Yes No
If yes, please indicate the name of the child welfare agency	______________________________________________________________

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